Registration & Assessment - Muscle Peptides Australia

This is a medical consultation, and the doctors require the patient to be honest to ensure quality advice is provided.

Are you an athlete in a sport that subscribes to the WADA World Anti-Doping Code?*

What are some of you Goals?

What do you expect to achieve?

Do you have any blood tests done recently that will give us more information about you?

Name*

First Middle Last

Email address*

Enter Email Confirm Email

Address*

Street Address

Suburb/City State / Province / Region

ZIP / Postal Code

Country

Phone Number*

Date of Birth*

Gender*

Male
Female

Create Your Profile

Create Username*

Password*

Enter Password Confirm Password

Weight (kg)*

Height (cm)*

Past Medical History

Have you ever been admitted to hospital in your life past or recent?*

Details of Admission*

Have you had any form of cancer in the past?*

Details of Cancer and remission

Thyroid disease*

Details of thyroid disease and treatment

heart disease*

Details of heart disease and treatment

Other

Medications

Do you smoke?*

Have you used peptides before?*

Which peptides did you use, at what daily dose, for how long and when?

Current medications name

Daily dose / frequency

Add more

Allergies

Do you have any allergies to medications?*

Please provide details

Medical Information

Medicare Number Details* Ensure medicare details are correct to reduce risk of account being declined

Agree*

I certify that all the information provided on this application is accurate to my knowledge

Please complete all the required fields. (Highlighted in red)

Complete below to be reviewed and approved

Create Your Profile

Create Your Profile

Medical Background Incomplete

Medical Background Incomplete

Current Medical History

Current Medical History

Past Medical History

Past Medical History

Medications

Medications

Allergies

Allergies

Medical Information

Medical Information